Cancer Navigation: A Discussion on Barriers and Obstacles All

Clinical Navigators Face

Sharon Gentry RN, MSN, AOCN, CBCNBreast Nurse Navigator

Derrick L Davis Forsyth Regional Cancer Center

Objectives

• Identify common types of barriers that healthcare clinical navigators may face.

• Explore solutions to address the barriers

• Share experiences among navigators on overcoming healthcare barriers

Defining barriers

• Barriers to health care are obstacles within our health care system that prevent vulnerable patient populations from getting needed health care, or that cause them to get inferior health care compared to advantaged patient populations.

• American Medical Student Association Foundation by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry. http://www.amsa.org/programs/barriers/intro.html

Potential Barriers toReceiving Timely Health Care

Freeman HP, Reuben SH. Voices of a Broken System. Bethesda, Md: NIH, NCI; 2001.

Financial and economic Lack of or inadequate insurance

Transportation Difficulty arranging transportation

Cultural Cultural beliefs regarding treatment

Communication and language Difficulty telling desires/needs

Health care system Fragmentation of care

Bias based on race/age Fear and mistrust by patients; inadequate screening of the elderly

Fear Delay or refusal of care

ExamplesBarrier

Types of Barriers• Geographic/Cultural

• Socioeconomic

• Organizational/Systemic

***Combination of above factors are likely to increase disparities of care

• Navigator role specific

Geographic/Cultural

Veteransborn prior 1946Affected by wars

Baby Boomers born between 1946 and 1964* largest population

Gen X was born between 1965 and 1979 “latchkey kids”

Gen Y was born between 1980 and 1995 Millennium or Net Generation.

Generation Z was born after 1995Digital Natives

Disciplined respect law & order.Consistency -do not like change.Fixed views on role gender and workplace.A directive, command & control management style.

Youth = open-minded and rebellious. Adult = more conservative.Job status and social standing are important. Tend to be optimistic, ambitious, & loyal. Employment is for life.

Both parents working.Daycare and divorce.Well-educated generation.Resourceful. Individualistic. Self reliant. Skeptical of authority.Focus on relationships, outcomes, their rights and skills.

Technology wise. Comfortable with ethnically diverse groups. Optimistic, confident, sociable, and strong morals with sense of civic duty.Not brand loyal. Flexible and changing in fashion, style consciousness.

Instant action and satisfaction.Smaller families with older Moms.Online communities and social media.Rather than personally meeting.not perform well in public speaking.

Geographic/Cultural

• Rural, suburban, inner-city…..• Veterans, Baby boomers, generations X, Y & Z

• health beliefs and behaviors• Patient beliefs as well as practitioner beliefs

Geographic/Cultural

Care

Language

Information

BiasFears

Health Literacy

• “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

US Dept of Health and Human Sciences

Teach back method

http://minorityhealth.hhs.gov/templates

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Examples

Following directions

Methods Commonly Used In U.S. Hospitals To Provide Language ServicesSource: Health Research and Educational Trust, 2006Robert Wood Foundation

One solution

Implicit Bias in Healthcare

Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here?Perm J. 2011 Spring; 15(2): 71–78. https://implicit.harvard.edu

Socioeconomic barriers“drivers of healthcare disparities”

• lack of health insurance• inability to pay out of pocket – transportation,

child care• Inadequate education• Employment issues• Psychosocial concerns

What is the socioeconomic status of the navigated population?

• Who are the people?Community profile 2015 Commission on Cancer requirement

Komen report

Census data

• EMPLOYMENT STATUS COMMUTING TO WORK OCCUPATION INDUSTRY CLASS OF WORKER INCOME AND BENEFITS

• HEALTH INSURANCE COVERAGE

• BELOW THE POVERTY LEVEL

http://factfinder2.census.gov/faces/tableservices/

Psychosocial Concerns

• Fear

• Mistrust

• Emotions

• Distress – *Distress monitoring for Commission on Cancer by 2015

Organizational/Systemic

Organizational/Systemic

Accessibility – • How accessible is your care ? Can the patient

find it?

• Physical barriers Accessible toilet and dressing rooms

http://www.cdc.gov/ncbddd/disabilityandhealth/accessibility.html

• Timely access for all

Organizational/SystemicCommunication

• “Removing Barriers to Health Care A Guide for Health Professionals” http://projects.fpg.unc.edu/~ncodh/rbar/

• Insufficient cultural sensitive information Drop-out – give up in misunderstanding or frustration

Organizational/Systemic

• Unspoken rules

• Chain of command

• Guarded reactions

Navigation as a Solution• Being there…trust

• Negative research (clinical trial) experiences

Unspoken Rules

• Family members are usually expected to keep problems a secret...

Navigator role specific

• Role definition

• Acceptance by leaders and peers

• Job sustainability

Barrier Solution• Cancer Patient Navigation Programs are designed to help patients receive the best care

possible. And they help the team that serves patients provide better care. Cancer Patient Navigation is not the cure for the disease, but it can be the lifesaver for the patient.